Chapter 104: Rheumatoid Arthritis: Joint Project Level II

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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

• Identify signs and symptoms of rheumatoid arthritis (RA) and assess disease severity and prognosis.

• Recommend appropriate non pharmacologic therapy for adjunctive management of RA.

• Recommend evidence-based, patient-specific analgesic, anti-inflammatory, and disease-modifying drug therapy for patients with RA.

• Develop an evidence-based, patient-specific monitoring plan to assess disease progress and evaluate the safety and efficacy of medication therapy.

• Educate patients and their families about the medications used to treat RA.

PATIENT PRESENTATION

Chief Complaint

“I am still very achy, I feel exhausted, and I am having a hard time getting going in the morning.”

HPI

Analise Schaefer is a 44-year-old African-American woman who presents to rheumatology clinic with complaints of generalized arthralgias, fatigue, and morning stiffness. She presented with similar symptoms 3 months ago, at which time she was started on naproxen and oral methotrexate. She reports a slight improvement in her symptoms relative to her visit 3 months ago.

PMH

• RA (moderate disease activity with features of poor prognosis) × 3 months

• Latent tuberculosis infection

FH

Father is alive and being treated for hypertension and osteoarthritis. Mother is alive and being treated for severe RA. Two siblings with no major health concerns.

SH

Tax accountant; married for 15 years; heterosexual, sexually active, monogamous. Denies tobacco or illicit drug use. Drinks one to two glasses of wine per week.

Meds

• Naproxen 500 mg PO twice daily

• Methotrexate 2.5 mg, six tablets (15 mg) PO once a week

• Folic acid 1 mg PO once daily

• Patient receives medications at a local community pharmacy. Medication profile indicates that she refills her medications on time the first of each month.

All

Sulfonamides—hives

ROS

Complains of swelling and pain in both hands; reports decreased ROM in hands and wrists; has morning stiffness every day for about 2 hours and fatigue daily during the afternoon hours; denies HA, chest pain, SOB, bleeding episodes, or syncope; no nausea, vomiting, diarrhea, loss of appetite, or weight loss.

Physical Examination

Gen

Caucasian woman in moderate distress because of pain, swelling, and fatigue related to arthritis

VS

BP 118/76 mm Hg, P 82 bpm, RR 14, T 37.1°C; Wt 65 kg, Ht 5′6″

Skin

No rashes; normal turgor; no breakdown or ulcers; no subcutaneous nodules

HEENT